The Graded Care Profile (GCP) scale was developed as a practical tool to give an objective measure of the care of children across all areas of need. Other scales in this field at best indicate whether the care environment is neglectful or not by comparing a score in a case with a reference score worked on a sample. In a given case, care could be bad in one area, not so bad or even good in another. This scale was conceived to provide a profile of care on a direct categorical grade. It is important from the point of view of objectivity because the ill effect of bad care in one area may be offset by good care in another area.
Instead of compartmentalising care into neglectful and non-neglectful, this scale draws on the concept of continuum. It has long been recognised that mothers are naturally disposed to care for and nurture their children to adulthood (Winnicott, 1957, Brimblecombe, 1979). However, the net care delivered is the product of interaction of the carer's disposition to care (caring instinct) with socio-familial circumstances, carer's attributes other than caring disposition and child's attributes. It can be enhanced if interacting factors are positive or eroded if negative. Thus, in the same case, care can vary if circumstances change. Based on different combinations of this interaction Belsky (Belsky, 1984) proposed eight grades of care on a bipolar continuum, best when all factors are positive and worst when negative. This scale is based on actual care by giving a grade to what the carer is doing in the way of caring without taking separate account of other factors. If those factors actually influenced the care then they are reflected in the same. Belsky's eight grades seemed difficult to work in practice. A practical approach was found in a long term prospective cohort study of children and families (Miller et al, 1960 & 1974). Here, care was categorised in three grades. ‘Satisfactory', if families provided everything that the child needed making extra effort if required, ‘unsatisfactory', if there was clear disregard for the child mixed with cruelty; ‘variable' if it was unpredictable.
In this scale there are five grades based on levels of commitment to care. Parallel with the level of commitment is the degree to which a child's needs are met and which also can be observed. The basis of separation of different grades is outlined in table 1 below.
|Grade 1.||Grade 2.||Grade 3.||Grade 4.||Grade 5.|
|All child's needs met||Essential needs fully met||Some essential needs unmet||Most essential needs unmet||Essential needs entirely unmet/hostile|
|Child first||Child priority||Child/carer at par||Child second||Child not considered|
1. = level of care; 2 = commitment to care; 3 = quality of care
These grades are then applied to each of the four areas of need based on Maslow's model of human needs – physical, safety, love and belongingness and esteem. This model was adopted not so much for its hierarchical nature but for its comprehensiveness. Each area is broken down into sub-areas, and some sub-areas to items, for ease of observation. A record sheet shows all the areas and sub-areas with the five grades alongside.
To help obtain a score, a coding manual is prepared which gives brief examples (constructs) of care in all sub-areas/items for all the five grades. From these, score for the areas are worked as per instructions.
Items and sub-areas are based on factors, which have been shown to bear relation to child development. Care component relating to the items/sub-areas are based more on intuitive than learnt elements (skills) keeping the interest of child uppermost as some skills themselves could be controversial and ever changing (e.g. nursing babies on their backs). This should minimise scores being affected by culture, education, and poverty, except in extreme circumstances.
Following its design, a field trial was conducted to assess its user friendliness and inter-rater reliability. It was found to be workable, user friendly, and gave a high inter-rater agreement. The inter-rater agreement was a measure of its consistency in getting the similar grade by different independent raters on the same case. Almost perfect level of agreement was achieved in the area of physical care (k = 0.899, 95%CI = 0.850 – 0.948), safety (k = 0.894; 95% CI = 0.854 – 0.933), and esteem
(k = 0.877; 95% CI = 0.808 – 0.946), and a substantial level in the area of love
(k = 0.785; 95% CI = 0.720 – 0.849). The mean time taken for scoring was 20 minutes (range 10 – 30) (Srivastava & Polnay, 1997).
It is a descriptive scale. The grades are qualitative and on the same bipolar continuum in all areas. Instead of giving a diagnosis of neglect it defines the care showing both strengths or weaknesses as the case may be. It provides a unique reference point. Changes after intervention can demonstrably be monitored in both positive and negative directions.
In practice it can be used in a variety of situations where care for children is of interest. In child protection it can be used in conjunction with conventional methods in assessment of neglect and monitoring; in other forms of abuse it can be used as an adjunct in risk and need assessment. Where risk appears low but care profile is poor it will safeguard the child by flagging up the issues, if it is good it will relieve any anxiety that there might be. Where risk is high and care profile is also poor it will strengthen the case and care will not be a forgotten issue, but if it is good it should not be used to downgrade the risk on its own merit as yet. In the context of children in need, it can help identify appropriate resources (depending on area of deficit) and target them. In the context of child health it can be used to identify care deficit where there is concern about growth, development and care, post-natal depression, repeated accidents, or simply where care is the sole concern.
Uniform care profile (same grade of care in all areas) poses less of a problem in decision making than uneven care profiles. From an intervention point of view it gives a point of focus. More work and experience is needed to know the true significance of uneven profiles.
Finally it should be remembered that it provides a measure of care as it is actually delivered irrespective of other interacting factors. In some situations where conduct and personality of one of the parents is of grave concern, a good care profile on its own should not be used to dismiss that fact. At present it brings the issue of care to the fore for consideration in the context of overall assessment.